DIFFERENCE IN RECOMMENDED-TO-ACTUAL NURSE STAFFING AND PATIENT FALLS by ...

123 Pages·2015·1.61 MB·English

DIFFERENCE IN RECOMMENDED-TO-ACTUAL NURSE STAFFING AND
PATIENT FALLS

by

SHAWN M. ULREICH

LARRY R. HEARLD, COMMITTEE CHAIR
S. ROBERT HERNANDEZ
STEPHEN J. O’CONNOR
PATRICIA A. PATRICIAN

A DISSERTATION

Submitted to the graduate faculty of The University of Alabama at Birmingham,
in partial fulfillment of the requirements for the degree of
Doctor of Science in Health Services Administration

BIRMINGHAM, ALABAMA

2015
Copyright by
Shawn M. Ulreich
2015
DIFFERENCE IN RECOMMENDED-TO-ACTUAL NURSE STAFFING AND
PATIENT FALLS
SHAWN M. ULREICH
EXECUTIVE DOCTORAL PROGRAM – SCHOOL OF HEALTH PROFESSIONS

ABSTRACT
Patient falls are a serious safety concern in hospitals. Injuries from falls can be
devastating to patients and are now subject to reimbursement penalties from the Center
for Medicare and Medicaid Services. Patient falls have been identified by the American
Nurses Association as a nursing sensitive indictor suggesting that improvements in the
quality or quantity of nurses may impact this outcome. Moreover, the literature suggests
that nurse staffing levels have an impact on various patient outcomes such as patient falls.
Therefore, identifying appropriate nurse staffing levels to minimize patient falls is
critically important to hospitals.
A variety of staffing metrics have been used to examine nurse staffing levels,
however, they are often criticized because of the level of measurement. This study
utilized a novel measure that examined the difference between recommended staffing and
actual staffing levels, at the shift level, and its association with patient falls. The
resource-based view of the firm served as the conceptual framework. The hypotheses for
this study posited that differences between recommended-to-actual staffing differences
will increase the likelihood of patient falls. More specifically, understaffing will increase
the likelihood of patient falls. Two hospitals within a large health system in the Midwest
served as the study sites, and all staffing and patient fall data were obtained from these
organizations. Results demonstrated no statistical significance between understaffing, and
patient falls when measured at the shift level. This study is the first to examine nurse
staffing and patient falls using the recommended-to-actual staffing metric at the shift
iii
level. As such, it provides a foundation on which subsequent research can be built.
Additionally, nurses and nurse leaders may want to consider alternative interventions to
reduce patient falls.

Keywords: nurse staffing, patient falls, nursing sensitive indicators, nursing staffing and
patient outcomes, resource-based view of the firm
iv
DEDICATION
This research is dedicated to the boundless efforts of nurses and nurse leaders
who struggle to balance the ever-increasing demands of patient care with safe and
responsible nurse staffing.

v
ACKNOWLEDGEMENTS
I am deeply grateful for the support and encouragement of my committee chair,
Dr. Larry Hearld and committee members Dr. S. Robert Hernandez, Dr. Stephen J.
O’Connor, and Dr. Patricia Patrician. Their sage wisdom and guidance has been
invaluable in my learning. I add a special note of thanks to Dr. Hearld for his patience
and innate ability to provide constructive criticism in a collegial and supportive manner.
Several colleagues were instrumental in obtaining the data for this study. First, I
thank Andrea Russell, who spent many hours over the holiday season, abstracting data in
a novel way. To Cara Knapp, whose passion for fall reductions has led to improvements
in care. And to Terry Popa, a colleague and confidant who spent hours of time in
gathering detailed staffing data, thank you for answering questions at any time of day or
night and for providing an endless supply of humor. I am forever grateful for the support
of my colleague and friend, Lisa Shannon, whose unwavering commitment to excellence
has served as a guidepost in my professional and academic development. To Carole
Montgomery, my friend and colleague, I thank you for providing emotional and
intellectual nourishment. And to my UAB colleagues, it is been a pleasure and honor to
be a part of this journey with you.
The love, support, and encouragement from my family has enabled me to pursue
this goal. To my husband and best friend Fred, thank you for believing in me, for never
complaining about my lack of presence, and for providing the best dinners at the end of
long days of studying and writing. To my daughters, Hannah and Halle, also fellow
vi
students, thank you for taking Dad on date nights, for the hilarious text messages, and the
lively discussions about collegiate life. We will all walk in 2015!

vii
TABLE OF CONTENTS
Page

ABSTRACT ....................................................................................................................... iii

DEDICATION .....................................................................................................................v

ACKNOWLEDGMENTS ................................................................................................. vi

LIST OF TABLES ............................................................................................................. xi

LIST OF FIGURES ......................................................................................................... xiii

LIST OF ABBREVIATIONS .......................................................................................... xiv

CHAPTER

1 INTRODUCTION .........................................................................................................1

Statement of the Problem ...............................................................................................1
Purpose of the Study ......................................................................................................5
Significance of the Study ...............................................................................................5

2 LITERATURE REVIEW ..............................................................................................7

Nurse Staffing and Patient Outcomes ............................................................................7
Quality Outcomes ..........................................................................................................7
Nursing Sensitive Indicators .......................................................................................7
Adverse Patient Outcomes/Events ..............................................................................8
Nurse Staffing Metrics ...................................................................................................9
Adverse Patient Outcomes/Events ...............................................................................11
Failure to Rescue.......................................................................................................11
Mortality ...................................................................................................................13
Medication Administration Errors ............................................................................14
Nursing Sensitive Indicators ........................................................................................15
Pressure Ulcers..........................................................................................................15
Catheter Associated Urinary Tract Infections...........................................................16
Patient Falls ...............................................................................................................16
Staffing .................................................................................................................16
Other Contributing Factors to Patient Falls ..........................................................22
Theoretical Framework ................................................................................................29
Donabedian’s Quality Outcome Model ....................................................................29

viii
Page

Resource-Based Theory of the Firm .........................................................................31

3 METHODOLOGY ......................................................................................................37

Study Design and Data Sources ...................................................................................37
Population and Data Sources ....................................................................................37
QuadraMed AcuityPlus® .....................................................................................38
Hospital Payroll System ......................................................................................38
Falls Database .....................................................................................................39
Data Warehouse ..................................................................................................39
Final Analytic Data Set .............................................................................................40
Human Subject Protection ........................................................................................40
Measures and Variables ...............................................................................................40
Dependent Variable ..................................................................................................40
Patient Falls .........................................................................................................40
Independent Variables ..............................................................................................41
Difference in Recommended-to-Actual Staffing ................................................41
Recommended Staffing .......................................................................................41
Actual Staffing ....................................................................................................43
Recommended-to-Actual Staffing ......................................................................44
Understaffing and Overstaffing ................................................................................44
Control Variables ......................................................................................................46
Statistical Analysis ....................................................................................................46

4 RESULTS ....................................................................................................................49

Descriptive Statistics ....................................................................................................49
Sample.......................................................................................................................49
Bivariate Analysis ........................................................................................................51
Staffing Differences ..................................................................................................51
Staffing Differences by Hospital ........................................................................51
Staffing Differences by Unit Type ......................................................................52
Staffing Differences by Shift ..............................................................................53
Patient Falls and Unit and Patient Characteristics ....................................................54
Patient Falls and Staffing Differences ......................................................................56
Multivariate Analysis ...................................................................................................57
Regression Analysis Model 1 ...................................................................................57
Regression Analysis Model 2 ...................................................................................58
Regression Analysis Model 3 ...................................................................................59
Supplemental Analysis..............................................................................................60

ix
Page

5 DISCUSSION ..............................................................................................................68

Explanation of Findings............ ...................................................................................68
Falls and Staffing Differences ..................................................................................68
Staffing Differences by Hospital ..............................................................................70
Staffing Differences between Unit Types .................................................................71
Staffing Differences by Shift ....................................................................................73
Implications of Findings............ ..................................................................................74
Recommendations for Future Research............ ...........................................................75
Limitations............ .......................................................................................................76
Summary............ ..........................................................................................................77

REFERENCES ..................................................................................................................78
APPENDICES ...................................................................................................................95
A NURSING-SENSITIVE INDICATORS ..............................................................95
B ACUITY PLUS INDICATOR DEFINITIONS ....................................................97
C UNIT TYPES BY HOSPITAL ...........................................................................102
D INSTITUTIONAL REVIEW BOARD APPROVAL FROM THE
UNIVERSITY OF ALABAMA AT BIRMINGHAM .......................................104
E INSTITUTIONAL REVIEW BOARD APPROVAL FROM SPECTRUM
HEALTH ............................................................................................................107

x